CMS Pub. 100-04, ch. 30, § 70.2

A. Triggering Events

A SNF ABN is evidence of beneficiary knowledge about the likelihood of a Medicare

denial, for the purpose of determining financial liability for expenses incurred for

extended care items or services furnished to a beneficiary and for which Medicare does

not pay. If Medicare is expected to deny payment (entirely or in part) on the basis of one

of the exclusions listed in §70 of this chapter for extended care items or services that the

SNF furnishes to a beneficiary, a SNF ABN must be given to the beneficiary in order to

transfer financial liability for the item or service to the beneficiary. The initiation,

reduction and termination of such extended care items or services, that Medicare may not

pay, are considered triggering events. The following describe the three triggering events

for a SNF ABN:

EVENT DESCRIPTION

Initiation In the situation in which a SNF believes Medicare

will not pay for extended care items or services

that a physician has ordered, the SNF must

provide a SNF ABN to the beneficiary before it

furnishes those non-covered extended care items

or services to the beneficiary.

Reduction

In the situation in which a SNF proposes to

reduce a beneficiary’s extended care items or

services because it expects that Medicare will

not pay for a subset of extended care items or

services, or for any items or services at the

current level and/or frequency of care that a

physician has ordered, the SNF must provide a

SNF ABN to the beneficiary before it reduces

items or services to the beneficiary.

Termination

In the situation in which a SNF proposes to stop

furnishing all extended care items or services to

a beneficiary because it expects that Medicare

will not continue to pay for the items or services

that a physician has ordered and the beneficiary

would like to continue receiving the care, the

SNF must provide a SNF ABN to the

beneficiary before it terminates such extended

care items or services.

B. Effect of Other Insurers/Payers

Some States have specific rules established regarding completion of liability notices in

situations where dual-eligibles need to accept liability for Medicare non-covered care that

will be covered by Medicaid. Medicaid has the authority to make this assertion under

Title XIX of the Act, where Medicaid is recognized as the “payer of last resort”, meaning

other Federal programs like Medicare (Title XVIII) must pay in accordance with their

own policies before Medicaid picks up any remaining charges. If the patient is a

Medicare-Medicaid dual-eligible and a triggering event occurs, the SNF needs to give the

beneficiary a SNF ABN.

On a practical basis, physician-prescribed items or services continue without interruption

or reduction when a patient changes “payer eligibility” from Medicare to Medicaid.

From the Medicare coverage vantage-point, however, there is a reduction or termination

when Medicare, which has been paying, stops paying. In other words, there is a

triggering event, which underlies the change in “payer eligibility.” In these instances, a

SNF ABN must be issued to transfer financial liability to the beneficiary.